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STATE OF CALIFORN116 WATER RESOURCES CONTROARD <br /> FORM 'S': UNDERGROUND STORAGE TANK PROGRAM <br /> TANK TANK PERMIT APPLICATION INFORMATION tlm <br /> CqMPLETE A SEPARATE FORM WITH THE FOLLOWI FORMATION FOR EACH TANK. a <br /> MARK ONLY 1NEW PERMIT �3RENEWAL PERMIT <br /> ONE ITEM 2 INTERIM PERMIT CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED TANK <br /> 4 AMENDED PERMIT 6 TEMPORARY TANK CLOSURE <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: / ❑6 TANK REMOVED O <br /> I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN- / FARM TANK-YES II NO <br /> SO SPECIFY <br /> A. OWNERS TANK ID# ilk -a <br /> B. MANUFACTURED BY <br /> C. YEAR INSTALLED <br /> D TANK CAPACITY <br /> GALL <br /> INS <br /> I1. TANK C NTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKEDIN OMPLOE7E ITEM D. <br /> A. W <br /> I MOTOR VEHICLE FUEL 2 PETROLEUM B (J) <br /> C. <br /> 3 CHEMICAL PRODUCT 4 OIL <br /> 1 UNLEADED 2 LEADED 3 DIESEL W <br /> � <br /> 5 HAZARDOUS 60 EMPTY 95 UNKNOWN I PRODUCT Ej 4 GASAHOL 5 JET FUEL E16 AVIATION GAS <br /> 2 WASTE 7 METHANOL ED gg OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.# <br /> xlll. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,E D CA S.#: <br /> A TYPE OF ❑ I OBLE WALLED 0 3 SINGLE WALLED WITH EXTERIOR LINER <br /> SYSTEM ElKsINGUE WALLED ❑95 UNKNOWN <br /> 4 SECONDARY CONTAINMENT <br /> 99 OTHER <br /> B.TANK El I STEEUIRON El 2 STAINLESS STEEL 3 FIBERGLASS <br /> MATERIAL ❑ 5 CONCRETE 6 POLYVINYL CHLORIDE 7 MINUM 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC <br /> El 9 BRONZE 10 GALVANIZED STEEL ❑95 UNKNOWN 6 100%METHANOL COMPATIBLE FRP <br /> 99 OTHER <br /> C. INTERIOR E] I RUBBERLINED 0 2 ALKYD LINING 3 EPDXY LINING 0 4 ENOLIC LINING <br /> LINING ❑5 GLASS LINING El 6 UNLINED <br /> E] IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? 95 UNKNOWN <br /> YES 0 NO [:]99 OTHER <br /> D. CORROSION ❑ 1 POLYETHLENEWRAP E]2 TARORASPHALT <br /> PROTECTION 3 LWRAP <br /> 5 CATHODIC PROTECTION 91 NONE ❑4 FIBERGLASS REINFORCED PLASTIC <br /> 95 UNKNOWN 0 99 OTHER <br /> IV. PIPING INFORM ON CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> LT' <br /> TYPE A u sucrloN A u UCTION A U 1 SINGLE WALLED A A U 3 GRAVITY A U 9g OTHER <br /> U 2 DOUBLEA U 1 STEEL/IRON A U 5 UNKNOWN A U 99 OTHER <br /> L A U 2 STAINLESS STEEL A U 3 POLYVINYLCHLORIDE( ) A U 4 FIBERGLASS PIPE <br /> A U 5 ALUMINUM A 6 CONCRETE <br /> A U 9 GALVANIZED STEEL A U 95 UNKNOWN A U 7 STEEL CLAD W/FRP A U 6100%METHANOL COMPATIBLE FRP <br /> A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> P 1 VISUAL CHECK P 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> P PRECISION TESTING P S 7 PRESSURETESTING P S 91 NONE P S 95 UNKNOWN <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE P s 9s OTHER <br /> I. ESTIMATED DATE LAST USED(MO/VR) <br /> 2. ESTIMATED QUANTITY OF <br /> SUBSTANCE REMAINING IN 9. WAS TANK FILLED WITH <br /> GALLONS INERT MATERIAL? YES 0 NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED S SIGNATURE) <br /> DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# <br /> FACILITY ID# TANK ID# <br /> V O O <br /> CURRENT LOCAL AGENCY FACILITY ID# algzUBI <br /> CAPPROVED BY NAME ZJ PHONE p WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE llQddA <br /> I PERMIT EXPIRATIO DATE <br /> CHECK# PERMIT AMOUNT SURCHARGE AMT. <br /> FEE CODE ECEIPTk <br /> BY: <br /> FORM B(3-7.88) THIS FORM MUST BE ACCOMPANIED BYA FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA HAS BEEN FILED <br /> DATA PROCESSING COPY <br />